LEMONE AND BURKE'S MEDICAL-
SURGICAL NURSING
CLINICAL REASONING IN PATIENT CARE
7TH EDITION
AUTHOR(S)GERENE BAULDOFF RN,
PHD, FAAN; PAULA GUBRUD;
MARGARET CARNO
TEST BANK
1) MCQ
Clinical Scenario:
A 74-year-old patient is 2 hours post-op after abdominal
surgery. The patient is restless, reports shortness of breath, has
,a respiratory rate of 28/min, and the oxygen saturation is 88%
on room air.
Question Stem:
What is the nurse’s priority action?
Answer Options:
A. Encourage the patient to take slow deep breaths
B. Apply oxygen and activate the rapid response system per
policy
C. Reassess the incision for bleeding
D. Document the findings and recheck in 30 minutes
Correct Answer:
B. Apply oxygen and activate the rapid response system per
policy
Detailed Rationale:
The patient shows acute deterioration with probable
hypoxemia, which threatens airway/breathing and can rapidly
progress to respiratory failure. Immediate oxygen and
escalation of care are the safest first actions. Deep breathing
may help later, but it is not enough for an unstable patient.
Incorrect Option Analysis:
A: May help a stable patient, but it delays urgent
treatment. This reflects the misconception that all
respiratory issues should be managed with comfort
measures first.
, C: Incision assessment is important, but breathing takes
priority over wound assessment.
D: Unsafe delay. Hypoxemia requires immediate action,
not observation.
Nursing Process Linkage:
Assessment / Implementation
Clinical Judgment Competencies (NCJMM):
Recognize Cues, Prioritize Hypotheses, Take Action
Clinical Reasoning Focus:
Cue Recognition, Priority Setting
Difficulty Level: Moderate
Bloom’s Cognitive Level: Apply
NCLEX Client Needs Category:
Physiological Adaptation
Key Learning Objective:
Prioritize immediate nursing actions when a patient shows
signs of acute respiratory compromise.
2) SATA
Clinical Scenario:
A medical-surgical unit is revising its pressure injury prevention
workflow after a recent increase in hospital-acquired pressure
injuries.
, Question Stem:
Which actions reflect evidence-based practice and use of a
care bundle? Select all that apply.
Answer Options:
A. Review current clinical guidelines and systematic reviews
B. Continue the same routine because it has “always worked”
C. Combine evidence with patient preferences and risk status
D. Audit staff compliance with the prevention bundle
E. Choose interventions based only on the loudest staff opinion
F. Track pressure injury rates after implementation
Correct Answers:
A, C, D, F
Detailed Rationale:
Evidence-based practice uses the best available evidence,
clinical expertise, and patient values. A care bundle works best
when it is standardized, audited, and evaluated for outcomes.
Incorrect Option Analysis:
B: Unsafe tradition-based practice; it ignores updated
evidence.
E: Opinion alone is not evidence and may lead to
inconsistent care.
Nursing Process Linkage:
Planning / Implementation / Evaluation
SURGICAL NURSING
CLINICAL REASONING IN PATIENT CARE
7TH EDITION
AUTHOR(S)GERENE BAULDOFF RN,
PHD, FAAN; PAULA GUBRUD;
MARGARET CARNO
TEST BANK
1) MCQ
Clinical Scenario:
A 74-year-old patient is 2 hours post-op after abdominal
surgery. The patient is restless, reports shortness of breath, has
,a respiratory rate of 28/min, and the oxygen saturation is 88%
on room air.
Question Stem:
What is the nurse’s priority action?
Answer Options:
A. Encourage the patient to take slow deep breaths
B. Apply oxygen and activate the rapid response system per
policy
C. Reassess the incision for bleeding
D. Document the findings and recheck in 30 minutes
Correct Answer:
B. Apply oxygen and activate the rapid response system per
policy
Detailed Rationale:
The patient shows acute deterioration with probable
hypoxemia, which threatens airway/breathing and can rapidly
progress to respiratory failure. Immediate oxygen and
escalation of care are the safest first actions. Deep breathing
may help later, but it is not enough for an unstable patient.
Incorrect Option Analysis:
A: May help a stable patient, but it delays urgent
treatment. This reflects the misconception that all
respiratory issues should be managed with comfort
measures first.
, C: Incision assessment is important, but breathing takes
priority over wound assessment.
D: Unsafe delay. Hypoxemia requires immediate action,
not observation.
Nursing Process Linkage:
Assessment / Implementation
Clinical Judgment Competencies (NCJMM):
Recognize Cues, Prioritize Hypotheses, Take Action
Clinical Reasoning Focus:
Cue Recognition, Priority Setting
Difficulty Level: Moderate
Bloom’s Cognitive Level: Apply
NCLEX Client Needs Category:
Physiological Adaptation
Key Learning Objective:
Prioritize immediate nursing actions when a patient shows
signs of acute respiratory compromise.
2) SATA
Clinical Scenario:
A medical-surgical unit is revising its pressure injury prevention
workflow after a recent increase in hospital-acquired pressure
injuries.
, Question Stem:
Which actions reflect evidence-based practice and use of a
care bundle? Select all that apply.
Answer Options:
A. Review current clinical guidelines and systematic reviews
B. Continue the same routine because it has “always worked”
C. Combine evidence with patient preferences and risk status
D. Audit staff compliance with the prevention bundle
E. Choose interventions based only on the loudest staff opinion
F. Track pressure injury rates after implementation
Correct Answers:
A, C, D, F
Detailed Rationale:
Evidence-based practice uses the best available evidence,
clinical expertise, and patient values. A care bundle works best
when it is standardized, audited, and evaluated for outcomes.
Incorrect Option Analysis:
B: Unsafe tradition-based practice; it ignores updated
evidence.
E: Opinion alone is not evidence and may lead to
inconsistent care.
Nursing Process Linkage:
Planning / Implementation / Evaluation
